Nina S. Parikh

Clinical Associate Professor of Social and Behavioral Sciences

Dr. Nina S. Parikh has years of public health research experience, methodological expertise, and academic training in health services research and medical sociology. A continuing theme of Dr. Parikh’s research involves the examination of social, psychosocial, and cultural factors related to the health needs of ethnic-racial populations and developing evidence-based strategies that address and mitigate health inequities for these and other underserved groups, in particular immigrants, the uninsured, those with inadequate health literacy, and the elderly.

At NYU GPH, Dr. Parikh collaborates with scholars examining the social determinants of health, particularly social network mechanisms and how they relate to primary and secondary prevention of vascular diseases. This work builds on her previous research experience that has been community-based, grant-funded studies in partnership with local agencies and organizations that explore the well-being of older adults and their families, including social cohesion/social support, access to and utilization of health care services of immigrant populations, health disparities, community-based palliative care for chronically ill elders, and the promotion of healthy aging with a particular emphasis on developing and implementing behavioral strategies to combat some of the most prevalent chronic conditions for this group. In addition, Dr. Parikh developed and teaches the two-semester thesis course to MPH candidates.

Prior to coming to NYU, Dr. Parikh served as the Director of Research (Interim) at the Brookdale Center for Healthy Aging of Hunter College where she provided oversight and guidance on all research and evaluation studies conducted by the Center. Her work has received grant support from the Robert Wood Johnson Foundation, the Commonwealth Fund, Agency for Healthcare Research and Quality, and the NYC Department for the Aging.

Chronic Physical Illness Burden and Suicidal Ideation Among Dominicans in New York City

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Little is known about the association between chronic illness and suicidal ideation (SI) among Dominicans living in the United States. This study used data from a community survey of 2753 Dominican adults in New York City. SI included thoughts of self-harm or being better off dead in the past month. Chronic physical illness burden was categorized as having 0, 1, or 2+ diagnosed conditions. Adjusted logistic regressions evaluated the association between number of conditions and SI, overall and stratified by sex and age. Adjusted models yielded a strong association between chronic illness burden and SI among men [odds ratio (OR) 5.57, 95 % confidence interval (CI) 2.19–14.18] but not women (OR 0.80, 95 % CI 0.50–1.29; interaction p = 0.011). The association of interest did not differ significantly between younger and older adults. Screening for SI in health care practice, particularly among Dominican men with multiple chronic health conditions, may be warranted.

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Objectives: Post-stroke depression (PSD) is common and associated with poor stroke outcomes, but few studies have examined race/ethnic disparities in PSD. Given the paucity of work and inconsistent findings in this important area of research, our study aimed to examine race/ethnic differences in depression in a multi-ethnic cohort of stroke patients. Design: Longitudinal. Setting: Prospective trial of a post-stroke educational intervention. Patients or Participants: 1,193 mild/moderate ischemic stroke/transient ischemic attack (TIA) patients. Main Outcome Measures: We used the Center for Epidemiologic Studies Depression (CES-D) Scale to assess subthreshold (CES-D score 8-15) and full (CES-D score ≥ 16) depression at one month ("early") and 12 months ("late") following stroke. Multinomial logistic regression analyses examined the association between race/ethnicity and early and late PSD separately. Results: The prevalence of subthreshold and full PSD was 22.5% and 32.6% in the early period and 22.0% and 27.4% in the late period, respectively. Hispanics had 60% lower odds of early full PSD compared with non-Hispanic Whites after adjusting for other covariates (OR=.4, 95% CI: .2, .8). Race/ ethnicity was not significantly associated with late PSD. Conclusions: Hispanic stroke patients had half the odds of PSD in early period compared with Whites, but no difference was found in the later period. Further studies comparing trajectories of PSD between race/ ethnic groups may further our understanding of race/ethnic disparities in PSD and help identify effective interventions.

Examining Barriers and Practices to Recruitment and Retention in Stroke Clinical Trials

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BACKGROUND AND PURPOSE: The National Institutes of Health policy calls for the inclusion of under-represented groups, such as women and minorities, in clinical research. Poor minority recruitment and retention in stroke clinical trials remain a significant challenge limiting safety and efficacy in a general population. Previous research examines participant barriers to clinical trial involvement, but little is known about the investigator perspective. This study addresses this gap and examines researcher-reported barriers and best practices of minority involvement in stroke clinical trials.METHODS: Quantitative and qualitative methods, including surveys, focus groups, and key informant interviews were used.RESULTS: In a survey of 93 prominent stroke researchers, 43 (51.2%; 70% response rate) respondents reported proactively setting recruitment goals for minority inclusion, 29 respondents (36.3%) reported requiring cultural competency staff training, and 44 respondents (51.2%) reported using community consultation about trial design. Focus groups and key informant interviews highlighted structural and institutional challenges to recruitment of minorities, including mistrust of the research/medical enterprise, poor communication, and lack of understanding of clinical trials. Researcher-identified best practices included using standardized project management procedures and protocols (eg, realistic budgeting to support challenges in recruitment, such as travel/parking reimbursement for participants), research staff cultural competency and communication training, and developing and fostering community partnerships that guide the research process.CONCLUSIONS: This study's formative evaluation contributes a new dimension to the literature as it highlights researcher-reported barriers and best practices for enhancing participation of minority populations into stroke clinical trials.

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As the older adult population grows and becomes more diverse, more of its members are turning to complementary and alternative medicine (CAM). There are mixed findings regarding racial and ethnic differences in the use of CAM. This article explores racial and ethnic differences in use of a category of CAM known as mind-body techniques (MBT) among senior center participants with symptoms of depression. It also examines the relationship between use of MBT and depression severity. A cross-sectional survey was conducted with a representative sample of senior center participants in New York City, from which a subsample of those with depressive symptoms was drawn. Racial and ethnic differences in MBT use were identified, as was a significant negative relationship between MBT use and depression severity. African American elders were more likely to have used MBT than other racial or ethnic groups. When controlling for race or ethnicity, health status, and barriers to medical care, predictors of depression severity included health status, experiencing barriers to medical care, and Hispanic identity. Findings suggest that being female or younger is associated with a higher likelihood of using CAM. Contrary to some prior research, education level was not associated with use of MBT.

Linking neighborhood characteristics to food insecurity in older adults: The role of perceived safety, social cohesion, and walkability

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Among the 14.6% of American households experiencing food insecurity, approximately 2 million are occupied by older adults. Food insecurity among older adults has been linked to poor health, lower cognitive function, and poor mental health outcomes. While evidence of the association between individual or household-level factors and food insecurity has been documented, the role of neighborhood-level factors is largely understudied. This study uses data from a representative sample of 1,870 New York City senior center participants in 2008 to investigate the relationship between three neighborhood-level factors (walkability, safety, and social cohesion) and food insecurity among the elderly. Issues relating to food security were measured by three separate outcome measures: whether the participant had a concern about having enough to eat this past month (concern about food security), whether the participant was unable to afford food during the past year (insufficient food intake related to financial resources), and whether the participant experienced hunger in the past year related to not being able to leave home (mobility-related food insufficiency). Unadjusted and adjusted logistic regression was performed for each measure of food insecurity. Results indicate that neighborhood walkability is an important correlate of mobilityrelated food insufficiency and concern about food insecurity, even after controlling the effects of other relevant factors.

Racial and Ethnic Diversity in Senior Centers: Comparing Participant Characteristics in More and Less Multicultural Settings

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The 2008 Health Indicators Project surveyed a probability sample (N = 1,870) of New York City senior center participants. Attendees of racially and ethnically diverse and nondiverse senior centers were compared across 5 domains: demographics; health and quality of life; social support networks; neighborhood perceptions and engagement; health service access/utilization. Although homogeneous and diverse center participants demonstrate similar health and quality-of-life outcomes, those from diverse centers demonstrate greater risk of social isolation, receive less family support, and more likely seek medical care from hospitals or community clinics. Implications and future directions for research, practice and policy are discussed.

The association between neighbourhood social cohesion and hypertension management strategies in older adults

The influence of neighborhood factors on the quality of life of older adults attending New York City senior centers: Results from the Health Indicators Project

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Purpose To examine the association between selfassessed quality of life (QOL) and perceived neighborhood safety, social cohesion, and walkability among older adults in New York City (NYC). Methods We used data from the 2008 Health Indicators Project, a cross-sectional survey of 1,870 older adults attending 56 NYC senior centers. QOL, a binary measure, was created by dichotomizing a 5-point Likert-scaled global assessment. Neighborhood safety, social cohesion, and walkability were multi-component scale variables that were standardized due to varying response metrics. Multivariate binomial logistic regression analysis was performed on 1,660 participants with complete data. Results After adjusting for covariates, QOL was significantly associated with neighborhood safety and social cohesion. A one-standard deviation increase in neighborhood safety and social cohesion increased the log odds of having higher QOL by 30% (odds ratio (OR) = 1.30; 95% confidence interval (CI) = 1.14, 1.48; P ≤ 0.001) and 36% (OR = 1.36; 95% CI = 1.16, 1.59; P ≤ 0.001), respectively. Higher QOL was not significantly associated with neighborhood walkability. Conclusion The results of this study underscore the need for initiatives that focus on enhancing age-friendly neighborhood features in large urban centers such as NYC and beyond.

Ethnic disparities in self-reported oral health status and access to care among older adults in NYC

Shelley, D., Russell, S., Parikh, N., & Fahs, M.

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2011

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Journal of Urban Health

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88

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There is a growing burden of oral disease among older adults that is most significantly borne by minorities, the poor, and immigrants. Yet, national attention to oral heath disparities has focused almost exclusively on children, resulting in large gaps in our knowledge about the oral health risks of older adults and their access to care. The projected growth of the minority and immigrant elderly population as a proportion of older adults heightens the urgency of exploring and addressing factors associated with oral health-related disparities. In 2008, the New York City Health Indicators Project (HIP) conducted a survey of a representative sample of 1,870 adults over the age of 60 who attended a random selection of 56 senior centers in New York City. The survey included questions related to oral health status. This study used the HIP database to examine differences in self-reported dental status, dental care utilization, and dental insurance, by race/ethnicity, among community-dwelling older adults. Non-Hispanic White respondents reported better dental health, higher dental care utilization, and higher satisfaction with dental care compared to all other racial/ethnic groups. Among minority older adults, Chinese immigrants were more likely to report poor dental health, were less likely to report dental care utilization and dental insurance, and were less satisfied with their dental care compared to all other racial/ethnic groups. Language fluency was significantly related to access to dental care among Chinese immigrants. Among a diverse community-dwelling population of older adults in New York City, we found significant differences by race/ethnicity in factors related to oral health. Greater attention is needed in enhancing the cultural competency of providers, addressing gaps in oral health literacy, and reducing language barriers that impede access to care.

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Background: It has been shown that as immigrants' length of residence increases, so does their weight. However, little is known about factors associated with weight status among Chinese Americans, one of the fastest growing immigrant populations in the US. Methods: Baseline datafrom a National Cancer Institute-funded longitudinal study involving a multi-stage probability sample of Chinese Americans residing in two communities in New York City were collected. Results: Chinese Americans had a low BMI (mean = 22.81) and a lower proportion of obese individuals compared with other ethnic groups in the US reported in the literature. While the prevalence of being overweight (21%) and obese (2%) was low, length of residence was positively associated with weight status (P &lt;0.005). Conclusions: Innovative strategies to help Chinese Americans maintain healthy weight status and to prevent them from becoming overweight and obese are needed.

Health behaviors of older Chinese adults living in New York City

Parikh, N., Fahs, M. C., Shelley, D., & Yerneni, R.

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2009

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Journal of Community Health

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34

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The dramatic increase in the number of older immigrants living in the U.S. presents new challenges to policy makers concerned with promoting healthy aging. To date, however, strikingly little is known regarding the health and health trajectories of older immigrants. This paper examines the prevalence and predictors of important health behaviors associated with chronic disease prevention, including current smoking status, physical activity, alcohol use, and body mass index (BMI). We analyzed data from the 2003 New York City Chinese Health Survey (NYC CHS), the largest probability-based sample of Chinese immigrants residing in two distinct communities. In-person interviews were conducted with 517 representative men and women aged 55-75. Logistic regression modeling was used to test the influence of demographic, socioeconomic status, acculturation, and health characteristics on selected health behaviors. Results revealed that having more education and better physical health status were associated with greater participation in physical activity. Gender-specific analyses indicated that the effect of selected predictors varied between the sexes. For example, among older Chinese women, acculturation was negatively associated with alcohol use. This study provides some of the first evidence on health behaviors of one of the fastest growing older immigrant groups in the U.S. Study results add to the emerging literature on the complex nature of immigrant health trajectories, and demonstrate that contrary to prior research, living a greater proportion of time in the U.S. can be associated with selected positive health behaviors. Further longitudinal studies are needed to help inform policy initiatives to encourage healthy aging among diverse older immigrant groups.

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We investigated patients' willingness to have their reading ability documented in their medical records and the degree of shame and embarrassment associated with such disclosure. Structured interviews were conducted among a consecutive sample of 283 primary care patients at an urban public hospital. Patients' literacy was measured using the Rapid Estimate of Adult Literacy in Medicine (REALM). Self-report of degree of shame and embarrassment related to literacy skills was measured using an orally administered questionnaire. Fifty-one percent of patients had low literacy skills (≤sixth grade) and 27.9% were assessed as having marginal literacy (seventh-eighth grade). Half (47.6%) of patients reading at or below the third-grade level admitted feeling ashamed or embarrassed about their difficulties reading, compared with 19.2% of those reading at the fourth-sixth-grade level and 6.5% of those reading at the seventh-eighth-grade level (p

Effect of an STD/HIV behavioral intervention on women's use of the female condom

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Objectives. This study assessed the effectiveness of a sexually transmitted disease (STD)/HIV behavior change intervention in increasing women's use of the female condom. Methods. A total of 604 women at high risk for STDs and HIV in New York City, Baltimore, Md, and Seattle, Wash, enrolled in a randomized controlled trial of a small-group, skills-training intervention that included information and skills training in the use of the female condom. Results. In a logistic regression, the strongest predictors of use were exposure to the intervention (odds ratio [OR] = 5.5; 95% confidence interval [CI] = 2.8, 10.7), intention to use the female condom in the future (OR= 4.5; 95% CI = 2.4, 8.5), having asked a partner to use a condom in the past 30 days (OR= 2.3; 95% CI = 1.3, 3.9), and confidence in asking a partner to use a condom (OR = 1.9; 95% CI= 1.1, 3.5). Conclusions. Clinicians counseling women in the use of the female condom need to provide information, demonstrate its correct use with their clients, and provide an opportunity for their clients to practice skills themselves.

Emergency department use in New York City: a substitute for primary care?

Billings, J., Parikh, N., & Mijanovich, T.

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2000

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Issue brief (Commonwealth Fund)

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433

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For the uninsured and many low-income people, hospital emergency departments (EDs) are a crucial entryway to the health care system. New York City's uninsured-27 percent of the nonelderly population in 1998, up from 20 percent in 1990-rely heavily on the ED for their medical care. Residents who regularly get their health care at an ED do not have regular doctors or continuity in their care, use costlier services, and often receive treatment that could have been avoided. Low-income New Yorkers may be depending on emergency department care even more as Medicaid enrollment declines and physician reimbursement rates are cut. This Issue Brief describes patterns of ED use through-out New York City and discusses some of the ways to improve the availability of primary care services and reduce ED dependency.

Emergency department use in New York City: a survey of Bronx patients.

Billings, J., Parikh, N., & Mijanovich, T.

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2000

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Issue brief (Commonwealth Fund)

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435

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1-5

Emergency department use: the New York Story.

Billings, J., Parikh, N., & Mijanovich, T.

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2000

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Issue brief (Commonwealth Fund)

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434

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Factors influencing participation in weekly support groups among women completing an HIV/STD intervention program

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Over the past three decades, the influence and importance of social support has been well documented and the findings have suggested a beneficial effect on stress-related situations, mental and physical health, and social functioning. More recently, small group/skills training behavioral interventions have demonstrated success in changing behaviors which affect the transmission of sexually transmitted diseases, including HIV among populations at risk for these diseases. Studies of support groups to date have been conducted exclusively in research settings where women are offered financial incentives for participation. Little is known about the willingness of women to participate in ongoing support groups after successfully completing a skills training intervention. The present study examines the factors that may influence participation among women in a weekly support group after completing a structured, six session HIV/ STD intervention. Both quantitative and qualitative data are collected from 265 women in the intervention arm of a multi-site randomized controlled behavioral intervention trial. Results reveal that less than a quarter (22%) of women participated in at least one support group. Participation varied significantly by site, ranging from 34% to 15% (p = .008). Participation was also strongly linked to recent use of domestic violence services. Qualitative data indicated that although monetary incentives play some role in the woman's decision to participate, other factors are also important. These include program outreach, support group size, salience of the group content, consistency of group leadership from the intervention to the support group, and use of peer leaders along with professional facilitators. Implications for design of post-intervention support groups programs are discussed.

Shame and health literacy: The unspoken connection

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Illiteracy is a well known national crisis, yet relatively little research has focused on how low literacy affects patients' health care experiences. The purpose of this study was to determine the relationship between shame and low functional literacy in the health care setting. It hypothesized that many patients with low literacy may not admit they have difficulty reading because of shame. Patients who presented for acute care at a large, public hospital in Atlanta, Georgia were interviewed. A total of 202 predominately indigent African-American patients completed a demographic survey, the Test of Functional Health Literacy in Adults (TOFHLA) and answered questions about difficulty reading and shame. Of the 202 patients interviewed, 42.6% had inadequate or marginal functional health literacy. Patients with low literacy were more likely to be male (P &lt;0.05), have less than a high school education (P &lt;0.01) and be over the age of 60 (P &lt;0.01). Of those patients with low literacy, 67.4% admitted having trouble reading and understanding what they read. Almost 40% (n = 23) of patients with low functional literacy who acknowledged they have trouble reading admitted shame. Of the, 58 patients who had low functional health literacy and admitted having trouble reading, 67.2% had never told their spouses, and 53.4% had never told their children of their difficulties reading. Nineteen percent of patients had never disclosed their difficulty reading to anyone. Many patients with reading problems are ashamed and hide their inability to read. Shame is a deeply harbored emotion that plays an important role in understanding how low literate patients interact with health care providers. Further research is needed to understand how providers should deal with the shame associated with low literacy.

The Health Care Experience of Patients with Low Literacy

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Objectives: To understand the difficulties that patients with poor reading ability have interacting with the health care system and to identify the coping mechanisms they use to deal with these problems. Design: Focus groups and individual interviews with patients who are illiterate and patients with low literacy. Setting: Two large, urban public hospitals. Participants: Sixty patients with marginal to poor reading abilities as measured by the Rapid Estimate of Adult Literacy in Medicine were interviewed in focus groups or individual interviews. Measurements and Main Results: Patients with low literacy harbor a deep sense of shame, which is reinforced by hospital staff who become frustrated or angry when someone cannot complete a form or read instructions. Seeking medical care is intimidating for patients with low literacy because they cannot understand signs and registration forms. Many patients recounted serious medication errors resulting from their inability to read labels. To cope with these problems, the patients with low literacy rely heavily on oral explanations, visual clues, and demonstrations of tasks to learn new material. Most also use a friend or family member as a surrogate reader. Conclusions: Patients with poor reading ability have important problems accessing the health care system, understanding recommended treatments, and following the instructions of providers. Because of their shame, patients with low literacy may be unwilling to disclose their problem to health care providers, and screening tests of reading ability may be necessary to identify those who need special assistance. Patients' coping mechanisms give insight into possible interventions that may improve their interactions with the health care system.

Inadequate Functional Health Literacy Among Patients at Two Public Hospitals

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To determine the ability of patients to complete successfully basic reading and numeracy tasks required to function adequately in the health care setting. -Cross-sectional survey. -Two urban, public hospitals. -A total of 2659 predominantly indigent and minority patients, 1892 English-speaking and 767 Spanish-speaking, presenting for acute care. -Functional health literacy as measured by the Test of Functional Health Literacy in Adults (TOFHLA), an instrument that measures ability to read and understand medical instructions and health care information presented in prose passages and passages containing numerical information (eg, prescription bottle labels and appointment slips). -A high proportion of patients were unable to read and understand written basic medical instructions. Of 2659 patients, 1106 (41.6%) were unable to comprehend directions for taking medication on an empty stomach, 691 (26%) were unable to understand information regarding when a next appointment is scheduled, and 1582 (59.5%) could not understand a standard informed consent document. A total of 665 (35.1%) of 1892 English-speaking patients and 473 (61.7%) of 767 Spanish-speaking patients had inadequate or marginal functional health literacy. The prevalence of inadequate or marginal functional health literacy among the elderly (age ≥60 years) was 81.3% (187/230) for English-speaking patients and 82.6% (57/69) for Spanish-speaking patients, and was significantly higher (P